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STATEOFCADFORMA c STATE WATER RESOURCES CONTROL BOARD UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM B COMPLETE A SEPARATE FORM FOR EACH TANK SYSTEM MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION rl 7 PERMANENTLY CLOSED ONSITE ONE REM ❑ 2 INTERIM PERMIT ❑ A AMENDED PERMIT ❑ 5 TEMPORARY TANK CLOSURE �j�jf S TANK REMOVED DBA OR FACILITY NAME WHERE TANK IS NSTALLED: me 3 I. TANK DESCRIPTION COMPLETE ALL ITEMS- SPECIFY IF UNKNOWN A. OWNER'S TANK I.O.• B. MANUFACTURED BY: Lw 1 C. DATE INSTALLED(MO/DAWYEAR) D. TANK CAPACITY IN GALLONS; JLTANKCONTENTS IFA-I ISMARKEO.COMPLETE ITEMC. ULAR A. 1 MOTOR VEHICLE FUEL ❑ 4 OIL B. C. ❑ IaUNLEADED 3 DIESEL ❑ S AVIATIONGAS 2 PETROLEUM ❑ BO EMPTY 1DPREMIUM 4 GASAHOL ❑ 7 METHANOL ❑ 3 CHEMICAL PRODUCT ❑ BS UNKNOWN ❑ 2 WASTE 1❑��2UD LEADEDpS JET L OTHER (DESCRIBE IN ITEM D. BELOW) D. IF(A.1)IS NOT MARKED, ENTER NAME OF SUBSTANCE STORED C.A.S.s: Ili. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOXES A,B.AND C.AND ALL THAT APPLIES IN BOX D AND A. TYPE OF ❑ 1 DOUBLE WALL ❑ 3 SINGLE WALL WITH EXTERIOR LINER OS UNKNOWN SYSTEM ❑ 2 SINGLE WALL ❑ 4 SECONDARY CONTAINMENT (VAULTEDTANK) ❑ IW OTHER B. TANK ❑ I BARE STEEL ❑ 2 STAINLESS STEEL ❑ 3 FIBERGLASS ❑ 4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC MATERIAL ❑ 5 CONCRETE ❑ S POLYVINYL CHLORIDE ❑ 7 ALUMINUM a B 100% METHANOL COMPATIBLE WIFRP (Primary Tmk) ❑ B BRONZE ❑ 10 GALVANIZED STEEL 95 UNKNOWN W OTHER ❑ 1 RUBBER LINED ❑ 2 ALKYD LINING ❑ 3 EPDXY LINING ❑ 4 PHENOLIC LINING C.I uNNIOR ❑ 5 GLASS LINING ❑ S UNLINED �B5 UNKNOWN E] W OTHER IS LINING MATERIAL COMPATIBLE WITH 100% METHANOL? YES_ No D.CORROSION ❑ I POLYETHYLENE WRAP ❑ 2 COATING ❑ 3 VINYL WRAP ❑ 4 FIBERGLASS REINFORCED PLASTIC PROTECTION ❑ 5 CATHODIC PROTECTION ❑ 91 NONE/I,,'' fSTIYS UNKNOWN ❑ 92 OTHER ,,,,��--,,,,�,,�� 11 E.SPILL AND OVERFILL SPILL CONTAINMENT INSTALLED(YEAR)y��W OVERFILL PREVENTION EQUIPMENT INSTALLED(YEAR)�F 8LQk) IV.PIPING INFORMATION CIRCLE A IFA13OVEGFIOUNDOR U IF UNDERGROUND,BOTH IF APPLICABLE A. SYSTEM TYPE A U I SUCTION A W2 PRESSURE A U 3 GRAVITY A U W OTHER B. CONSTRUCTION A U I SINGLE WALL A U 2 DOUBLE WALL A U 3 LINED TRENCH A V,95 UNKNOWN A U 30 OTHER C. MATERIAL AND A U I BARE STEEL A U 2 STAINLESS STEEL A U 3 POLYVINYL CHLORIDE(PVC)A U 4 FIBERGLASS PIPE CORROSION A U 5 ALUMINUM A U S CONCRETE A U 7 STEEL W/COATING A U B 100% METHANOL COMPATIBLE W/FRP PROTECTION A U S GALVANIZED STEEL A U 10 CATHODIC PROTECTION A UNKNOWN A U W OTHER D. LEAK DETECTION ❑ 1 AUTOMATIC LINE LEAK DETECTOR ❑ 2 LINE TIGHTNESS TESTING ❑ MONRgi1NG 99 OTHER V.TANK LEAK DETECTION ❑ I VISUAL CHECK ❑ 2 INVENTORY RECONCILIATION ❑ 3 VADOZE MONITORING ❑ 4 AUTOMATIC TANK GAUGING ❑ 5 GROUND WATER MONITORING ❑ S TANK TESTING ❑ 7 INTERSTITIAL MONITORING ❑ 91 NONE 54 SS UNKNOWN ❑ W OTHER VI.TANK CLOSURE INFORMATION 1. ST ED DATELOT USED(MO/D!(Y/Vji)� 2.ESTIMATED QUANTITY OF 3.WAS TANK FILLED WITH YES NO❑ ``C�i SUBSTANCE REMAINING GALLONS INERT MATERIAL? THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT DATE ,GP,NTED NATUNEI \ IYT J I`I�JC�JI 1�/L-I f��N CO LOCAL AGENCY USE ONLY THE STATE I.D.NUMBER IS COMPOSED OF THE FOUR NUMBERS BELOW COUNTY I JURISDICTION O FACILITY S TANK s Q0 STATE I.D.# m lzlg5! O 4 PERMIT NUMBER PERMIT APPROVED BY/DATE PERMIT EXPIRA I KIN DATE THIS FORM MUST BE ACCOMPANIED BY A PERMIT APPLICATION•FORM A,UNLESS A CURRENT FORM A HAS BEEN FILED. FILE THIS FORM WITH THE SAL AGENCY IMPLEMENTING THE UNDERGROUND STOR TANK REGULATIONS FORM B 112.31) `y �� FORMS-R9